Prevalence and Associated Risk Factors of Endoparasites among Under-Five Children in Debre Tabor Comprehensive Specialized Hospital, Debre Tabor, Northwest Ethiopia: A Cross-Sectional Study

Many endoparasites are still considered neglected tropical illnesses. The term “endoparasites” refers to infections caused by both helminths and protozoa. In many places in Ethiopia, particularly Debre Tabor, epidemiological data on the prevalence and associated variables of endoparasites among under-five children is unavailable. Thus, the aim of this study was to gather baseline data on the prevalence of endoparasites and their associated variables among under-five children who visited the Debre Tabor comprehensive specialized hospital in Northwest Ethiopia. A hospital-based quantitative cross-sectional study was used. The study was carried out from May 1 to November 30, 2021. Study participants were selected by a systematic sampling technique. The stool specimen was examined for the presence of different stages of intestinal parasites (adult, trophozoite, larvae, cysts, and ova) using direct wet mount, modified formal-ether sedimentation, and modified Ziehl–Neelsen methods. The IBM SPSS statistical package (version 23) was used to enter and analyze the collected data. The data was summarized using frequency tables and a bar chart. The adjusted odds ratio and p value <0.05 were used to declare the final association. In the present study, a total of 258 under-five children and their mothers/guardians were involved in the study, with a response rate of 100%. More than half of the respondents, 137 (53.10%), were females, and 159 (61.63%) were in the age group of 24 to 59 months. The overall prevalence of one or more endoparasites among under-five children was 45 (17.44%). Multivariate logistic regression analysis showed that health supervision, child food freshness, regular trimming of fingernails, and children's playground cleanliness were significantly associated with childhood endoparasites. The present study demonstrated a higher prevalence of endoparasites among under-five children. Health supervision, child food freshness, regular trimming of fingernails, and children's playground cleanliness were significantly associated with endoparasites. Thus, strengthening health education about food, personal, and environmental hygiene for both children and their mothers/guardians is crucial.


Introduction
Many endoparasites are still considered neglected tropical illnesses. The term "endoparasites" refers to infections caused by both helminths and protozoa [1]. The symptoms of endoparasites include anemia, asthma, weight loss, fatigue, low immune system, nervousness, skin rash, diarrhea, vomiting, loss of appetite, digestive disorders, abdominal discomfort, and an enlarged abdomen [2,3]. Children's physical and mental growth and development are harmed by chronic endoparasites in general. In addition, endoparasites may increase susceptibility to infections with other intestinal pathogens [4].
According to the World Health Organization, more than 270 million preschoolers and 600 million schoolchildren live in locations where parasites are widely spread [5]. Studies have shown that endoparasites are a serious childhood health problem in several developing countries, including Ethiopia, where the problem is exacerbated by a poor environmental and personal hygiene, a lack of health knowledge, and poor socioeconomic situations [2,6,7]. Two-thirds (2/ 3) of African countries had high-risk areas with a prevalence of more than 50% [8].
Previous study has found a relationship between endoparasites and socioeconomic characteristics, with low maternal education, low family income, residing in a rural region, and poor sanitary facilities all being associated with a higher prevalence of endoparasites [22]. People become infected by ingesting infective stages of the parasites (eggs and cysts) or being bitten by the larvae stage of the parasites through contaminated soil, water, and undercooked meat and/or vegetables [23,24].
Endoparasites are frequent in under-five children and can be caused by a variety of factors, such as playing in the dirt, sucking fingers, or defecating in an open field. The prevalence of endoparasites is influenced by maternal understanding of their prevention and control. Regular antihelminthic therapy, increased access to potable water, sanitation, and health education are all important to limit the effects of endoparasites [3,10,25].
In many places in Ethiopia, particularly Debre Tabor, epidemiological data on the prevalence and associated variables of endoparasites among under-five children is unavailable. Because their immune systems have not fully developed, under-five children require extra attention and follow-up because they are more prone to heavy infections with endoparasites and other infectious diseases, and they frequently play in fecal-contaminated dirt [26,27]. Thus, the aim of this study was to gather baseline data on the prevalence of endoparasites and their associated variables among under-five children who visited the Debre Tabor comprehensive specialized hospital in Northwest Ethiopia. This information could help public health planners, policymakers, and implementers in developing and implementing effective intervention strategies to reduce related morbidity and mortality among under-five children.

Methods and Materials
2.1. Study Area. This study was conducted in the Debre Tabor comprehensive specialized hospital's pediatric ward.

Inclusion Criteria.
Under-five children who had sufficient stool and were not on an antiparasitic drug within one month before screening were included. Children who were critically ill and mothers/guardians who did not agree to give information about their children were excluded from the study.

Sample Size
Determination and Sampling Procedure. The sample size (n) for the prevalence of endoparasites was calculated using the single population proportion formula with an endoparasites rate of 18.7% (P) [12] at Woreta Health Center, a sampling error of 5% (d), and a 95% confidence interval (Zα/2). Based on the assumption of a 10% nonresponse rate, the final sample size was 258. The sample size for factors associated with endoparasites was calculated using OpenEpi version 3 and taking into account the study's 80% power, 95% two-sided confidence interval, 1 : 1 case to control ratio, and 10% nonresponse rate. To determine sample size, the least odds ratio and proportion of cases with exposure to factors linked to endoparasites in prior studies were chosen. As a result, sample size was determined by accounting for independent variables such as age, education, and occupation [11,16]. Finally, the survey's largest sample size (258) was considered. Study participants were selected by a systematic sampling technique; every fourth child was included based on the arrival order of their hospital visit.
2.5. Data Collection Tool. Data was collected using a structured interview questionnaire, which was prepared after an intensive review of related literature on the topic [2,5,6,[10][11][12][13][14][15][16][17][18][19][20][21]. The tool contained two parts. The first part embraced questions about the sociodemographic profile of respondents, such as gender and age of child, family residence, religion, ethnicity, occupation, mother/guardian's educational status, and family income. The second part was categorized into two subheadings. The first was to inquire about health information. The second was characteristics of food, personal, and environmental hygiene. The data collection tool was initially prepared in an English version, which was later translated into an Amharic version, the local language, and then retranslated to English for analysis to ensure consistency (Supplementary material 1). The content validity was determined by a team of specialists from the fields of public health, medical laboratory science, epidemiology, and biostatistics. The final version of the questionnaire contained a reliable indicator, which was a good sign (as indicated by the Alpha Cronbach test value of 0.902).

Data Quality Control and the Data Collection Processes.
One week prior to the actual data collection period, the questionnaire was pretested on 13 under-five children served in Ebinat Primary Hospital, Northwest Ethiopia, to ensure its appropriateness. It was corrected and used after the pretest. The collected questionnaires were reviewed on a daily 3 Journal of Parasitology Research basis for completeness, accuracy, clarity, and consistency of data. Data was collected by four diploma nurses and two laboratory technologists by face-to-face interview in the local language (Amharic) using a structured questionnaire guide.
The stool specimen was examined for the presence of different stages of intestinal parasites (adult, trophozoite, larvae, cysts, and ova) using direct wet mount, modified formal-ether sedimentation, and modified Ziehl-Neelsen methods. A total of 258 fresh stool samples were collected in labeled vials and were processed within one hour of collection at the clinical parasitology laboratory, Debre Tabor comprehensive specialized hospital.
In the direct wet mount method, direct normal saline (0.85% NaCl solution) and Lugol's iodine wet mount of each sample were used to detect endoparasites microscopically. The wet mounts were examined under a light microscope (CX21FS1, Olympus Corporation, Philippines) at 100× and 400× magnifications. A small portion of the stool specimen was also preserved in 10% formalin for repeating the tests whenever required and for further analysis [20].
In the modified formal-ether sedimentation method, a portion of each preserved stool specimen was taken and processed. Briefly, 1 g of stool was placed in a clean conical centrifuge tube containing 7 mL of 10% formol water by using an applicator stick and shacked gently. The resulting suspension was filtered through a sieve into another conical tube. After adding 3-4 mL of diethyl ether to the formalin solution, the content was centrifuged at 3000 revolutions per minute for 1 minute. The supernatant was discarded, and the tube was reinstalled in its rack. Finally, a smear was prepared from the sediment and observed under a light microscope with a magnification of 100× and 400× [20]. The entire negative specimens and 10% of the total positive slides were randomly selected and reexamined by another blinded technician. To ensure the quality of the investigation, the two readers independently read the slides, and their readings were compared. Discordants were immediately resolved with a discussion of each other and in consultation with other experts. To ensure the validity of the slide test, all positive slides and a random sample of some negative slides were reexamined by another experienced laboratory technician who was blind to the first slide-reader's diagnosis.
For the modified Ziehl-Neelsen method, a smear from the remaining sediment was stained with carbol fuchsin for 15 minutes and fixed with methanol for 2-3 minutes. The stain was decolorized with 1% acid alcohol for 15 seconds and counterstained with methylene blue for 30 seconds [11].

Data
Processing and Analysis. The IBM SPSS statistical package (version 23) was used to enter and analyze the collected data [30]. The findings were presented using descriptive statistical methods (frequency and percentage). The data was summarized using frequency tables and a bar chart. Bivariant logistic regression was used to identify factors associated with endoparasites. The backward method was used. A reference variable was used to define the categorical variables, which was the last variable. An odds ratio and a p value were used to test the association. In the univariate analysis, factors having a p value < 0.2 were included in the multivariate analysis to control for the possible effect of confounders. Model fitness was checked using the Hosmer-Lemeshow test of goodness of fit before the actual logistic regression analysis. The adjusted odds ratio and p value < 0.05 were used to declare the final association.

Ethical
Consideration. An ethical clearance letter (reference number: RCC1103/21) was obtained from the research ethics review committee of the College of Health Sciences, Debre Tabor University. Permission to conduct the study was sought from the respective hospital authorities. Informed written consent was obtained from the mothers/ guardians of each child before enrolment in the study. Those mothers/guardians who were able to read and write signed the consent form themselves. Those who were unable to read and write provided their thumbprint after the information sheet, and consent form were read to them. The interview was not recorded on tape. Participants were informed that participation in the study was entirely voluntary and that they had the right to withdraw at any moment. Personal identities were not recorded on the questionnaire, and all data gathered through face-to-face interviews was kept with complete confidentiality. Besides, an explanation was given about the procedure of stool examination, which is noninvasive and causes no harm to the study participants, and the aim of the study result may benefit the study participants and the community as well. All the under-five children who were positive for any of the suspected intestinal parasites were linked to a pediatrician to be treated.

Sociodemographic Characteristics of the Participants.
In the present study, a total of 258 under-five children and their mothers/guardians were involved in the study, with a response rate of 100%. More than half of the respondents, 137 (53.10%), were females, and 159 (61.63%) were in the age group of 24 to 59 months. The majority of mothers/ guardians' religions (240, 93.02%) were orthodox, and (225, 87.21%) were of Amhara ethnicity. One hundred forty-two (55.04%) children were from families having a monthly income of between 2000 and 3000 Ethiopian Birr (Table 1).

Health Information of the Participants.
One hundred fifty-one (58.53%) of the mothers/guardians reported that they were frequently supervised by health professionals.

Journal of Parasitology Research
One hundred thirty-four (51.94%) mothers/guardians reported having received health messages 1 week before the time of the survey, and the commonest source of information was government health workers, which accounted for 122 (91.04%). One hundred thirty-seven (53.10%) mothers/guardians reported that they exchanged health information within the family on a weekly basis ( Table 2).

Characteristics of Food, Personal, and Environmental
Hygiene. In this study, the majority (217, 84.11%) of participants had clean dining utensils. More than half (150, 58.14%) and 165 (63.95%) of mothers/guardians wash their hands after toileting and trim their children's nails when grown, respectively. Two hundred thirty-four (90.70%) of mothers/guardians had tap water as a source of drinking  (Table 3).

Prevalence of Endoparasites.
The overall prevalence of one or more endoparasites among under-five children was 45 (17.44%). Among the identified intestinal parasites, the predominant one was Giardia lamblia 23 (51.11%), followed by Ascaris lumbricoides 12 (26.67%). The distribution of identified parasites among under-five children is described in Figure 1.

Risk Factors Associated with Endoparasites.
Multivariate logistic regression analysis showed that health supervision, child food freshness, regular trimming of fingernails, and children's playground cleanliness were significantly associated with childhood endoparasites. However, there was no statistically significant association between the endoparasites and other variables (p value >0.05). The prevalence of childhood endoparasites was 2.52 times higher among households that had not been frequently supervised by health professionals (AOR = 2:52, 95%CI = ½0:55, 1:50). Children who were rarely fed a fresh meal were 4.61 (AOR = 4:61, 95%CI = ½1:03, 4:12) more likely to be infected by endoparasites than children fed a fresh meal. Those children whose nails were trimmed sometimes were 3.26 (AOR = 3:26, 95 %CI = ½1:91, 9:25) more likely to be infected by endoparasites than children whose nails were cut always. Besides, children who did not have access to a clean playing ground were 2.67 times (AOR =2.67, 95% CI = [1.64, 6.01]) more likely to be infected by endoparasites than children who had access to a clean playing ground (Table 4).

Discussion
In underdeveloped nations, endoparasites are one of the primary causes of death among children [31]. To develop successful preventative and therapeutic approaches for child morbidity, it is critical to understand the distribution and extent of endoparasites in a specific population among susceptible groups such as children. The current study looked at the prevalence of endoparasites and associated risk factors among under-five children who visited the Debre Tabor comprehensive specialty hospital's pediatric ward.
Recently, the overall prevalence of one or more endoparasites among under-five children was 45 (17.44%). When the prevalence of endoparasites is less than 20%, it is considered the lowest in Ethiopia. According to the national classification of endoparasite prevalence, the finding of the current study has reached the lowest category. In addition, it is far from the short-term national target reduction of endoparasites of less than 1% in Ethiopia. So, it is impossible to meet the national target of eliminating parasites in 2020 [9]. The finding of this study was corroborated with what was found in Debre Birhan (17.4%) [5], Gondar (17.3%) [10], and Saudi Arabia (17.7%) [32]. This similarity could be due to the fact that studies used similar study designs and selected participants.
This study also showed low prevalence as compared with studies conducted in different parts of the world like Zambia (19.6%) [7], Sudan (24.9%) [34], Senegal (26.2%) [35], Uganda (26.5%) [36], Côte d'Ivoire (62.75%) [4], and Kenya (86%) [37]. The variation in prevalence could be due to the difference in geographical location, time of survey, varied characteristics of the study subjects, differences in sample size, implementation of different prevention and control measures, and socioeconomic status. However, the finding of our study is still higher according to the national safe environment strategy in the extension program in Ethiopia.
According to the prevalence rate of each parasite species, Giardia lamblia was the predominant prevailing parasite with a prevalence of 51.11%, followed by Ascaris lumbricoides (26.67%). This finding is comparable with the study conducted in Debre Birhan, Senbete and Bete, Wolaita Sodo, Nigeria, and Saudi Arabia [5,6,14,31,32], in which Giardia lamblia was most prevalent. Some studies indicated that the predominant parasite among children was E. histolytica/E. dispar [11,13,17]. This variation might be due to variations in study sample size and the involvement of different factors in the transmission of parasites. In the current study, double parasitic infections were detected in five children, which is similar to a study conducted in Debre Birhan five [5], whereas in Hawassa six [17], in Senbete and Bete towns 18 [6], and in Senegal 22 [35] children were infected with two parasites.
In this study, it was shown that health supervision, child food freshness, regular trimming of fingernails, and children's playground cleanliness were significantly associated with childhood endoparasites. The prevalence of endoparasites was higher among households that had not been frequently supervised by health professionals. Another study also reported the association of health supervision and endoparasites [16]. This fact can be justified by the fact that health supervision promotes health behaviors toward hygiene and sanitation practices. Health supervision increases knowledge and acceptability of interventions 7 Journal of Parasitology Research within the community. It also sustains integrated control of the infection.
Eating rarely fresh food was found to be a risk factor for endoparasites when compared to those who were fed always fresh food. This is because of the fact that storage of cooked food for a longer period gives rise to a proliferation of bacteria and other parasites. This result is supported by similar studies conducted in Ethiopia [18,20]. Irregular trimming of children's fingernails was also significantly associated with endoparasites. This result is supported by similar studies conducted in Ethiopia [5,12,18]. This could be attributed to the removal of accumulated dirt containing eggs of parasites on fingernails during trimming [38].
Children who had an unclean playground were found to be at an increased rate of having endoparasites (AOR = 2:67, 95%CI = ½1:64, 6:01). This is due to the presence of microorganisms and eggs of parasites on dirty surfaces. This is supported by a study which concluded that inadequate sanitation and hygiene behavior are associated with soiltransmitted helminths and intestinal protozoa infections [39].
In the present study, there was no significant association between gender and endoparasites. Similarly, other research studies in Ethiopia revealed the prevalence of endoparasites did not show any association with gender [5,15,17]. In contrast to this study finding, a study in Kenya showed an association between endoparasites and gender (p value =0.045) [40].
Mothers/guardians who had a low level of education had a higher risk of their children acquiring endoparasites than other mothers/guardians who had a higher education [5,32]. But the current study did not show an association between endoparasites and mothers/guardians' education status. This is in line with the study done in Dessie [11]. In contrast to this study's finding, other studies showed an association between endoparasites and drinking water from a river source and age [5,15,17].
Although these findings are limited to one hospital, because of the extensive range of health services provided to children in that hospital, they may represent the population of the area. All of this research suggests that intervention measures to reduce the spread of endoparasites in this context should be implemented effectively. Furthermore, for efficient control of endoparasites, this study highlights the importance of focused health education, health awareness, and cleanliness practices.

Limitations of the Study
There were only a few limitations to this study. First, because of the cross-sectional design, any potential temporal relationships were difficult to analyze. Second, some study variables may be subject to recall bias. Third, children are only recruited within two months, and there may be seasonal fluctuations in the prevalence of endoparasites in the study area. Finally, other factors that could influence the prevalence of endoparasites, such as family size, the number of rooms used to sleep, and contact with animals, were not addressed.

Conclusion
Endoparasites, primarily Giardia lamblia and Ascaris lumbricoides, were found to be relatively prevalent among under-five children in the study area. Despite the health intervention coverage of Ethiopians by the Ministry of Health, the present study demonstrated a higher prevalence of endoparasites among under-five children, which needs holistic and integrated efforts to control endoparasites. Health supervision, child food freshness, regular trimming of fingernails, and children's playground cleanliness were significantly associated with endoparasites. Thus, strengthening health education about food, personal, and environmental hygiene for both children and their mothers/ guardians is crucial. Besides, improving mothers/guardians' awareness about the mode of intestinal parasite transmission and prevention methods is necessary.

Data Availability
The datasets for analyzed the current study are available from the corresponding author upon reasonable request of him.

Disclosure
The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of the manuscript.